HOSPITAL BEDS
Corporate Medical Policy
File name: Hospital Beds
File code: UM.DME.08
Origination: 4/18/07
Last Review: 10/2011
Next Review: 10/2012
Effective Date: 2/01/2012
Document Precedence
BCBSVT Medical Policies are developed to provide guidance for members and providers
regarding coverage in accordance with all terms, conditions and limitations of the subscriber
contract. Benefit determinations are based in all cases on the applicable contract language. To
the extent that there may be any conflict between Medical Policy and contract language, the
contract language takes precedence.
Medical Policy
Description
Definitions:
Fixed height hospital bed: Manual head and leg elevation adjustments but no height adjustments.
Variable height hospital bed: Manual height adjustment and with manual head and leg elevation
adjustments.
Semi-electric hospital bed: Manual height adjustment and with electric head and leg elevation
adjustments.
Total electric hospital bed: Electric height adjustment and with electric head and leg elevation
adjustments.
Air Fluidized Bed: An air fluidized bed is a device employing the circulation of filtered air through
ceramic spherules (small, round ceramic objects) that is marketed to treat or prevent bedsores
or to treat extensive burns. An air fluidized bed uses warm air under pressure to set small
ceramic beads in motion, which simulate a fluid movement. When the patient is placed in the
bed, his/her body weight is evenly distributed over a large surface area, which creates a
sensation of floating.
Policy
The Plan provides benefits for the rental, rental to purchase or purchase of hospital beds based
upon medical necessity.
A fixed-height hospital bed (HCPCS codes E0250, E0251, E0290 or E0291) may be considered
medically necessary when:
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•
•
•
The member's condition requires positioning of the body; e.g., to alleviate pain, promote good
body alignment, prevent contractures, avoid respiratory infections, in ways not feasible in an
ordinary bed; or
The member requires the head of the bed to be elevated more than 30 degrees most of the
time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration.
Pillows or wedges must have been considered; or
The member's condition requires special attachments (e.g. traction equipment) that cannot be
fixed and used on an ordinary bed.
A variable-height bed may be indicated (HCPCS codes E0255, E0256, E0292, or E0293) when
criteria are met for a fixed-height bed and the individual requires a bed height other than that of a
fixed-height hospital bed to permit transfers to a chair, wheelchair or standing position.
A semi-electric bed may be indicated (HCPCS codes E0260, E0261, E0294, or E0295) when
criteria are met for a fixed-height hospital bed and the individual requires frequent changes in
body position, and/or has an immediate need for a change in body position, and is able to operate
the controls for adjustment.
A heavy-duty, extra-wide/bariatric bed may be indicated (HCPCS codes E0301 or E0303), when
criteria are met for a fixed-height bed and the individual’s weight is more than 350 pounds but
less than 600 pounds.
An extra-heavy-duty bed may be indicated (HCPCS codes E0302 or E0304), when criteria are
met for a fixed-height hospital bed and the individual weighs 600 pounds or more.
The Plan covers a pediatric hospital bed/crib (HCPCS E0300) as medically necessary when the
child meets criteria for any of the above hospital beds.
The Plan does not cover ANY of the following beds, as they are not considered to be appropriate
for use in the home care setting and therefore not medically necessary:
The use of institutional beds, kinetic therapy beds, Stryker frame beds, oscillating beds or other,
similar beds in the home care setting is considered inappropriate and not medically necessary.
For example, some institutional type and specialty beds (HCPCS E0270) deliver therapies that
are known as kinetic therapy and continuous lateral rotational therapy. The CDC (Centers for
Disease Control and Prevention) defines kinetic therapy as 40-degree rotation or greater to each
side using a specialty bed, and continuous lateral rotational therapy as delivering less than 40degree rotation to each side, also using a specialty bed. These types of beds are used to facilitate
drainage of pulmonary secretions and to relieve pressure. They are often used for patients with
spinal cord injuries or impaired respiratory function in an acute care hospital setting. Many clinical
studies have been conducted to research the clinical benefits of various degrees of rotation, but
all these studies have been conducted in acute care settings.
The Plan does not cover ANY of the following beds and accessories, as they are not primarily
medical in nature and therefore not medically necessary:
®
®
• All nonhospital adjustable beds (e.g., Craftmatic Adjustable Bed, Simmons
®
Beautyrest Adjustable Bed, Adjust-A-Sleep Adjustable Bed);
• Bed boards (HCPCS codes E0273, E0315);
• Bed elevators (e.g., blocks, lifters);
• Bed wedges/pillows;
• Bedrail pads;
• Custom bedroom equipment;
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• Mattresses (e.g., inner spring, foam rubber [HCPCS codes E0271, E0272], viscoelastic
®
or memory foam mattresses [e.g., Tempur-Pedic ], adjustable firmness/support
mattresses [e.g., Select Comfort]);
• Over bed tables (HCPCS code E0274), trays, lap boards;
• Power/manual lounge beds;
®
• Safety accessories, such as enclosures/canopies (HCPCS code E0316) (e.g., Vail
Enclosed Bed Systems, Posey Bed Canopy beds);
• Waterbeds
Use of the air fluidized bed is medically necessary when ALL of the following conditions are
met in patients who:
•
are bedridden and are unable to fully or partially ambulate; AND
•
have a stage 3 (full-thickness tissue loss) or stage 4 (deep tissue destruction)
pressure sore; AND
have exhausted conservative treatment without improvement; AND
in the absence of an air fluidized bed, the patient would require institutionalization;
AND
have a trained adult caregiver available to assist the patient with activities of daily
living, fluid balance, dry skin care, repositioning, recognition and management of
altered mental status, dietary needs, prescribed treatments, and management and
support of the air fluidized bed system and its problems such as leakage; AND
have a physician who directs the home treatment regimen, and reevaluates and
recertifies the need for the air fluidized bed on a monthly basis; AND
have utilized and ruled out all other alternative equipment. Such alternatives
include, but are not limited to, gel flotation pads, egg crate mattresses, and
pressure pads and pumps.
•
•
•
•
•
Home use of the air fluidized bed is not medically necessary under ANY of the following
circumstances:
•
•
•
•
the patient requires treatment with wet soaks or has moist wound dressings that
are not protected with an impervious covering such as plastic wrap; OR
the caregiver is unable to provide the type of care required by the patient on an
air fluidized bed; OR
structural support is inadequate to support the weight of the air fluidized system (it
weighs 1600 pounds or more); OR
the home electrical system is insufficient for the anticipated increase in energy
consumption.
Administrative and Contractual Guidance
Benefit Determination Guidance
Prior approval is required and benefits are subject to all terms, limitations and conditions of the
subscriber contract.
For New England Health Plan (NEHP) members an approved referral authorization is required.
Benefits for FEP members may vary. Please consult the FEP Service Plan brochure.
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The following information is required when requesting prior approval for a hospital bed:
•
•
•
•
A detailed clinical summary from a physician including, but not limited to, the member’s
diagnosis, summary of hospital stay if applicable, prognosis, and description of
disabilities requiring the functions of a hospital bed.
As noted above, clinical information must be submitted monthly to determine medical
necessity for ongoing use of an air fluidized bed
Anticipated length of time bed will be needed.
HCPCS code, and monthly rental and purchase price.
Eligible Providers
Durable Medical Equipment (DME) providers
Related Policies
Durable Medical Equipment (DME)
Policy Implementation/Update information
Reviewed by CAC 7/2007
3/2008 Annual review. Naturopathic Physician added as eligible provider. Reviewed by CAC
5/2008.
10/2011 Updated and transferred to new policy format. Policy language added concerning special
bed types. Definitions of standard hospital bed types added. Exclusions for accessories added.
Coding updated to reflect additions to policy.
Medical/Clinical Coder reviewed and approved 10/6/2011 SAF
Scientific Background and Reference Resources
1. Blue Cross and Blue Shield Association Medical Policy, Air Fluidized Beds 1.01.01
A search of literature was completed through the MEDLINE database for the period of
January 1992 through April 1995 following Medical Subject Headings: Decubitus; Prevention
and Control
Research was limited to English-language journals on humans.
2. See also:
Medicare Guidelines for Air Fluidized Bed
Approved by BCBSVT Medical Directors
Date Approved
Antonietta Sculimbrene MD
Chair, Medical Policy Committee
Robert Wheeler MD
Chief Medical Officer
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Attachment I
Covered Codes when medical
necessity criteria are met
HCPCS
Code
Description
E0194
E0196
E0197
E0250
Air fluidized bed
Gel pressure mattress
Air pressure pad for a mattress
Hospital bed fixed height with mattress and
any type side rails
Hospital bed fixed height without mattress
and any type side rails
Hospital bed variable height with mattress*
Hospital bed variable height without
mattress*
Hospital bed semi electric with mattress
Hospital bed semi electric without mattress
Hospital bed total electric with mattress
Hospital bed total electric without mattress
Powered pressure reducing air mattress
Hospital bed; fixed height, without side rails;
with mattress
Hospital bed; fixed height, without side rails;
without mattress
Hospital bed; hi-lo, without side rails; with
mattress*
Hospital bed; hi-lo, without side rails; without
mattress*
Hospital bed; semi-electric (head and foot
adjustment), without side rails; with mattress*
Hospital bed; semi-electric (head and foot
adjustment), without side rails; without
mattress*
Hospital bed; total electric (head and foot
adjustment), without side rails; with mattress*
Hospital bed; total electric (head and foot
adjustment), without side rails; without
mattress*
Pediatric crib hospital grade fully enclosed
Heavy duty hospital beds*
Non power pressure reducing mattress
Hospital bed, pediatric manual
Hospital bed, pediatric electric or semielectric
Powered air overlay for a mattress
*allowed when additional criteria described in
policy are met
Durable Medical Equipment, miscellaneous
Description
E0251
E0255
E0256
E0260
E0261
E0265
E0266
E0277
E0290
E0291
E0292
E0293
E0294
E0295
E0296
E0297
E0300
E0301-E0304
E0371, E0373
E0328
E0329
E0372
Not covered-not medically
necessary (member liability)
E1399
Code
E0270
Hospital bed institutional type with
oscillating/circulating and Stryker frame with
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E0271
E0272
E0273
E0274
E0315
E0316
mattress
Mattress innerspring
Foam rubber mattress
Bed Board
Over-bed Table
Bed accessory: board, table, or support
device, any type
Safety enclosure frame/canopy for use with
hospital bed, any type
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